<?php
session_start();
if ($_SERVER['REQUEST_METHOD'] == 'POST' && $_POST['formid'] == 'vakantie_boeken')
{
   if (isset($_POST['captcha'], $_SESSION['captcha']) && md5($_POST['captcha']) == $_SESSION['captcha'])
   {
      unset($_POST['captcha'], $_SESSION['captcha']);
   }
   else
   {
      $errorcode = file_get_contents('smartlink://page00000');
      $errorcode = str_replace('##error##', 'CAPTCHA verification failed.', $errorcode);
      echo $errorcode;
      exit;
   }
}
use PHPMailer\PHPMailer\PHPMailer;
use PHPMailer\PHPMailer\Exception;
require __DIR__.'/Exception.php';
require __DIR__.'/PHPMailer.php';
require __DIR__.'/SMTP.php';

function ValidateEmail($email)
{
   $pattern = '/^([0-9a-z]([-.\w]*[0-9a-z])*@(([0-9a-z])+([-\w]*[0-9a-z])*\.)+[a-z]{2,6})$/i';
   return preg_match($pattern, $email);
}
function ReplaceVariables($code)
{
   foreach ($_POST as $key => $value)
   {
      if (is_array($value))
      {
         $value = implode(",", $value);
      }
      $name = "$" . $key;
      $code = str_replace($name, $value, $code);
   }
   $code = str_replace('$ipaddress', $_SERVER['REMOTE_ADDR'], $code);
   return $code;
}
if ($_SERVER['REQUEST_METHOD'] == 'POST' && isset($_POST['formid']) && $_POST['formid'] == 'vakantie_boeken')
{
   $mailto = 'contact@malpieheide.nl';
   $mailfrom = isset($_POST['email']) ? $_POST['email'] : $mailto;
   $mailcc = 'jan@malpieheide.nl';
   $subject = 'Vakantie boeken';
   $message = 'Vakantie boeken';
   $success_url = './Vakantie_bevestiging.php';
   $error_url = './Vakantie_boeken.php';
   $mysql_server = 'localhost:3306';
   $mysql_database = 'vakantiehonden';
   $mysql_table = 'vakantiehonden';
   $mysql_username = 'AMH_malpieheid_vakantie';
   $mysql_password = 'Wimke2312!';
   $autoresponder_from = 'contact@malpieheide.nl';
   $autoresponder_name = 'Kennel van de Malpieheide';
   $autoresponder_to = isset($_POST['Email']) ? $_POST['Email'] : $mailfrom;
   $autoresponder_subject = 'Vakantie boeken';
   $autoresponder_message = 'Hallo Malpieheide,

Mijn hond komt bij jullie op vakantie.
Deze heb ik zojuist ingeboekt. (zie onder aan de mail)

Ik heb me op de hoogte gesteld van jullie huisregels en ik ga hiermee akkoord. 

Let op ; Op zondag is Malpieheide gesloten, ook voor het halen en brengen van honden.

DE EIGENAAR NEEMT EEN DAG VOOR AANKOMST MET JULLIE TELEFONISCH CONTACT OP OM DE DEFINITIEVE AANKOMSTTIJD AF TE SPREKEN.HIJ BELT HIERVOOR 06-55883341 OF 040-2068572
De eigenaar vergeet niet om: 
*    Het dierenpaspoort (of inentingsbewijs) mee te brengen.       
      Dit blijft gedurende de vakantie bij ons i.v.m. eventuele controle.
*    De gegevens van de contactpersoon in het dierenpaspoort te stoppen. 
Uw telefoonnummer of het telefoonnummer (en eventueel naam en adres) van een contactpersoon met wie we bij eventuele problemen contact op kunnen nemen.

Dit is een automatisch gegenereerde mail.
Als deze goed in uw mailbox is aangekomen, kunt u er van uit gaan dat deze ook in de mailbox van Malpieheide is gekomen.

Zonder tegenbericht is uw reservering accoord en uw hond van harte welkom bij ons in de door u aangegeven periode.

Groetjes,

Kennel van de Malpieheide
Valkenswaard


---';
   $eol = "\n";
   $error = '';
   $internalfields = array ("submit", "reset", "send", "filesize", "formid", "captcha", "recaptcha_challenge_field", "recaptcha_response_field", "g-recaptcha-response", "h-captcha-response");

   $mail = new PHPMailer(true);
   try
   {
      $mail->Subject = stripslashes($subject);
      $mail->From = $mailfrom;
      $mail->FromName = $mailfrom;
      $mailto_array = explode(",", $mailto);
      $mailcc_array = explode(",", $mailcc);
      for ($i = 0; $i < count($mailto_array); $i++)
      {
         if(trim($mailto_array[$i]) != "")
         {
            $mail->AddAddress($mailto_array[$i], "");
         }
      }
      for ($i = 0; $i < count($mailcc_array); $i++)
      {
         if(trim($mailcc_array[$i]) != "")
         {
            $mail->AddCC($mailcc_array[$i], "");
         }
      }
      if (!ValidateEmail($mailfrom))
      {
         $error .= "The specified email address (" . $mailfrom . ") is invalid!\n<br>";
         throw new Exception($error);
      }
      $mail->AddReplyTo($mailfrom);
      $message .= $eol;
      foreach ($_POST as $key => $value)
      {
         if (!in_array(strtolower($key), $internalfields))
         {
            if (is_array($value))
            {
               $message .= ucwords(str_replace("_", " ", $key)) . " : " . implode(",", $value) . $eol;
            }
            else
            {
               $message .= ucwords(str_replace("_", " ", $key)) . " : " . $value . $eol;
            }
         }
      }
      $mail->CharSet = 'ISO-8859-1';
      if (!empty($_FILES))
      {
         foreach ($_FILES as $key => $value)
         {
            if ($_FILES[$key]['error'] == 0)
            {
               if (is_array($_FILES[$key]['name']))
               {
                  $count = count($_FILES[$key]['name']);
                  for ($file = 0; $file < $count; $file++)
                  {
                     $mail->AddAttachment($_FILES[$key]['tmp_name'][$file], $_FILES[$key]['name'][$file]);
                  }
               }
               else
               {
                  $mail->AddAttachment($_FILES[$key]['tmp_name'], $_FILES[$key]['name']);
               }
            }
         }
      }
      $mail->WordWrap = 80;
      $mail->Body = $message;
      $mail->Send();
      if (!ValidateEmail($autoresponder_from))
      {
         $error .= "The specified autoresponder email address (" . $autoresponder_from . ") is invalid!\n<br>";
         throw new Exception($error);
      }

      $mail->ClearAddresses();
      $mail->ClearAttachments();
      $mail->Subject = stripslashes($autoresponder_subject);
      $mail->From = $autoresponder_from;
      $mail->FromName = $autoresponder_name;
      $mail->AddAddress($autoresponder_to, "");
      $mail->AddReplyTo($autoresponder_from);
      foreach ($_POST as $key => $value)
      {
         if (!in_array(strtolower($key), $internalfields))
         {
            if (!is_array($value))
            {
               $autoresponder_message .= ucwords(str_replace("_", " ", $key)) . " : " . $value . $eol;
            }
            else
            {
               $autoresponder_message .= ucwords(str_replace("_", " ", $key)) . " : " . implode(",", $value) . $eol;
            }
         }
      }

      $mail->IsHTML(false);
      $mail->WordWrap = 80;
      $mail->Body = $autoresponder_message;
      $mail->Send();
      $search = array("ä", "Ä", "ö", "Ö", "ü", "Ü", "ß", "!", "§", "$", "%", "&", "/", "\x00", "^", "°", "\x1a", "-", "\"", " ", "\\", "\0", "\x0B", "\t", "\n", "\r", "(", ")", "=", "?", "`", "*", "'", ":", ";", ">", "<", "{", "}", "[", "]", "~", "²", "³", "~", "µ", "@", "|", "<", "+", "#", ".", "´", "+", ",");
      $replace = array("ae", "Ae", "oe", "Oe", "ue", "Ue", "ss");
      foreach($_POST as $name=>$value)
      {
         $name = str_replace($search, $replace, $name);
         $name = strtoupper($name);
         if (is_array($value))
         {
            $form_data[$name] = implode(",", $value);
         }
         else
         {
            $form_data[$name] = $value;
         }
      }
      $db = mysqli_connect($mysql_server, $mysql_username, $mysql_password) or die('Failed to connect to database server!<br>'.mysqli_error($db));
      mysqli_query($db, "CREATE DATABASE IF NOT EXISTS $mysql_database");
      mysqli_select_db($db, $mysql_database) or die('Failed to select database<br>'.mysqli_error($db));
      mysqli_query($db, "CREATE TABLE IF NOT EXISTS $mysql_table (ID int(9) NOT NULL auto_increment, `DATESTAMP` DATE, `TIME` VARCHAR(8), `IP` VARCHAR(15), `BROWSER` TINYTEXT, PRIMARY KEY (id))");
      foreach($form_data as $name=>$value)
      {
         mysqli_query($db ,"ALTER TABLE $mysql_table ADD $name VARCHAR(255)");
      }
      mysqli_query($db, "INSERT INTO $mysql_table (`DATESTAMP`, `TIME`, `BROWSER`)
                   VALUES ('".date("Y-m-d")."',
                   '".date("G:i:s")."',
                   '".$_SERVER['HTTP_USER_AGENT']."')")or die('Failed to insert data into table!<br>'.mysqli_error($db)); 
      $id = mysqli_insert_id($db);
      foreach($form_data as $name=>$value)
      {
         mysqli_query($db, "UPDATE $mysql_table SET $name='".mysqli_real_escape_string($db, $value)."' WHERE ID=$id") or die('Failed to update table!<br>'.mysqli_error($db));
      }
      mysqli_close($db);
      $successcode = file_get_contents($success_url);
      $successcode = ReplaceVariables($successcode);
      echo $successcode;
   }
   catch (Exception $e)
   {
      $errorcode = file_get_contents($error_url);
      $replace = "##error##";
      $errorcode = str_replace($replace, $e->getMessage(), $errorcode);
      echo $errorcode;
   }
   exit;
}
?>
<!doctype html>
<html>
<head>
<meta charset="utf-8">
<title>Kennel van de Malpieheide</title>
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<div class="col-1">
<div id="wb_Breadcrumb1" style="display:inline-block;width:100%;z-index:0;vertical-align:top;">
<ul id="Breadcrumb1">
<li><a href="https://www.malpieheide.nl">Malpieheide&#174;</a></li>
</ul>

</div>
</div>
<div class="col-2">
<div id="wb_ThemeableMenu1" style="display:inline-block;width:100%;z-index:1;">
<div id="ThemeableMenu1" class="ThemeableMenu1" style="width:100%;height:auto !important;">
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</button>
</div>
<div class="ThemeableMenu1-navbar-collapse collapse">
<ul class="nav navbar-nav">
<li class="nav-item">
<a href="https://www.malpieheide.nl" title="Dierenspullen" class="nav-link"><i class="fa fa-home"></i>Home</a>
</li>
<li class="nav-item dropdown">
<a href="#" class="dropdown-toggle" data-toggle="dropdown" >Malpieheide<b class="caret"></b></a>
<ul class="dropdown-menu">
<li class="nav-item"><a href="#Welkom" title="Welkom bij Malpieheide" class="nav-link">Welkom</a></li>
<li class="nav-item"><a href="" target="_blank" title="Algemene info Malpieheide" class="nav-link">Algemeen</a></li>
<li class="divider"></li>
</ul>
</li>
<li class="nav-item dropdown">
<a href="#" class="dropdown-toggle" data-toggle="dropdown" >Contactinformatie<b class="caret"></b></a>
<ul class="dropdown-menu">
<li class="nav-item"><a href="#Contact" title="Contact Malpieheide" class="nav-link">Contact</a></li>
<li class="nav-item"><a href="./Vakantie_boeken.php" target="_blank" title="Vakantie boeken" class="nav-link">Vakantie boeken</a></li>
</ul>
</li>
<li class="nav-item dropdown">
<a href="#" class="dropdown-toggle" data-toggle="dropdown" >Pupinfo<b class="caret"></b></a>
<ul class="dropdown-menu">
<li class="nav-item"><a href="" title="Afspraak maken" class="nav-link">Afspraak maken</a></li>
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</div>
</div>
</div>
<div id="Welkom" style="position:relative;text-align:center;width:100%;height:144px;float:left;clear:left;display:block;z-index:89;">
<div id="Welkom_Container" style="width:970px;position:relative;margin-left:auto;margin-right:auto;text-align:left;">
<div id="wb_Text9" style="position:absolute;left:0px;top:83px;width:499px;height:40px;text-align:center;z-index:2;">
<span style="color:#96866D;font-family:'Comic Sans MS';font-size:21px;">LEUK DAT U ONZE KENNEL EEN BEZOEKJE BRENGT .....</span><span style="color:#000000;font-family:Arial;font-size:24px;"><br></span></div>
</div>
</div>
<div id="wb_LayoutGrid5">
<div id="LayoutGrid5-overlay"></div>
<div id="LayoutGrid5">
<div class="row">
<div class="col-1">
</div>
<div class="col-2">
<div id="wb_Heading2" style="display:inline-block;width:100%;z-index:3;">
<h1 id="Heading2">Vakantie boeken</h1>
</div>
<div id="wb_Text3">
<p style="font-size:16px;line-height:18px;">&nbsp;</p>
<p style="font-size:16px;line-height:18px;">Ga je op vakantie en wil je dat je hond bij ons op vakantie komt, </p>
<p style="font-size:16px;line-height:18px;">dan kun je via onderstaand formulier gelijk de vakantie van je hond boeken.</p>
<p style="font-size:13px;line-height:16px;">&nbsp;</p>
</div>
<div id="wb_Text13">
<p style="font-size:13px;line-height:16px;">Vakantieopvang enkel en alleen voor met ons in relatie staande honden.&nbsp;&nbsp;&nbsp; </p>
<p style="font-size:13px;line-height:16px;"> (Dus b.v. de door ons gefokte honden.)</p>
<p style="font-size:13px;line-height:16px;">&nbsp;</p>
<p style="font-size:13px;line-height:16px;">Dus niet voor vakantieopvang voor alle honden en alle rassen. </p>
<p style="font-size:13px;line-height:16px;">Zie hiervoor www.dekwispelhoeve.nl</p>
<p style="font-size:13px;line-height:16px;">&nbsp;</p>
<p style="font-size:13px;line-height:16px;">&nbsp;</p>
<p style="font-size:13px;line-height:16px;">&nbsp;</p>
</div>
<div id="wb_Text17">
<span style="color:#F5F5F5;font-family:Arial;font-size:20px;"><strong><em>Brengen en halen tussen 10.00 uur en 16.00 <br>           Maandag t/m zaterdag. <br><br>          Op zondag zijn wij gesloten, <br>dus ook voor halen en brengen van honden !!</em></strong></span>
</div>
<div id="wb_Text14">
<p style="font-size:13px;line-height:16px;">&nbsp;</p>
<p style="font-size:19px;line-height:21px;">&nbsp;</p>
<p style="font-size:19px;line-height:21px;"><a href="javascript:displaylightbox('Vakantie-hond.pdf',{})" target="_self">Klik hier voor onze huisregels &gt;&gt;&gt;&gt;</a></p>
<p style="font-size:13px;line-height:16px;">&nbsp;</p>
</div>
</div>
</div>
</div>
</div>
<div id="wb_Toekomst">
<div id="Toekomst">
<div class="row">
<div class="col-1">
<div class="col-1-padding">
<div id="wb_Image15" style="display:inline-block;width:100%;height:auto;z-index:8;">
<img src="images/vakantie-hond.gif" id="Image15" alt="Vakantie hond en fijne vakantie" width="890" height="1107">
</div>
</div>
</div>
</div>
</div>
</div>
<div id="wb_Contact">
<div id="Contact">
<div class="row">
<div class="col-1">
<div class="col-1-padding">
</div>
</div>
<div class="col-2">
<div id="wb_Image3" style="display:inline-block;width:100%;height:auto;z-index:9;">
<img src="images/Malpieheide-Swiss-Dogs.gif" id="Image3" alt="" width="616" height="224">
</div>
</div>
</div>
</div>
</div>
<div id="wb_LayoutGrid2">
<div id="LayoutGrid2">
<div class="row">
<div class="col-1">
<div class="col-1-padding">
<div id="wb_Text2">
<span style="color:#F5F5F5;font-family:Arial;font-size:43px;"><strong>Contactinformatie</strong></span><h1><br><br></h1><span style="color:#6C757D;font-family:Arial;font-size:24px;">Ons adres: <br><br>Bergeijksedijk 2<br>5556 XJ Borkel en Schaft<br>gemeente Valkenswaard<br><br>Telefoon/fax: 040-2068572<br><br>www.malpieheide.nl<br>contact@malpieheide.nl<br><br>Openingstijden<br><br>Maandag t/m zaterdag <br>van 10.30 uur tot 15.00 uur<br><br>Op zondag zijn wij gesloten.<br><br><br><br></span>
</div>
</div>
</div>
<div class="col-2">
<div id="wb_Text7">
<span style="color:#6C757D;font-family:Arial;font-size:24px;">De aan ons hangende nummers:<br><br>Bewijs van Vakbekwaamheid<br>No 5565<br><br>Kennel registratie Raad van Beheer<br>No 33842<br><br>De Gezondheidsdienst voor Dieren<br>UBN 2834229<br><br>Rijksdienst voor ondernemend Nederland<br>UBN 6354561<br><br>Aequor Erkend Leerbedrijf<br>Reg.nr.: 226 933<br><br>Dibevo, PVH, LICG<br>Sympathiserend meediscuserend betreffende Gezondheid en Welzijn dieren richting Overheid.<br><br>Kamer van Koophandel<br>17162902<br>BTW nummer: NL 1429.30.775.B01<br><br>Elektronische post: MALPIEHEIDE &gt;&gt;<br><br></span>
</div>
</div>
</div>
</div>
</div>
<div id="wb_contact">
<div id="contact">
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<h2 id="contactHeading1"><br>Neem contact met ons op.<br><br></h2>
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<p>Helaas worden we in de coronatijd overvallen met vragen. </p>
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<p>Niet altijd mogelijk om een antwoord te geven.</p>
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<input type="text" id="Editbox7" style="display:block;width: 100%;height:42px;z-index:16;" name="email" value="" spellcheck="false" placeholder="Email address" data--100-bottom="transform:translate(0%,0px);" data-bottom-top="transform:translate(200%,0px);">
<input type="text" id="Editbox9" style="display:block;width: 100%;height:42px;z-index:17;" name="subject" value="" spellcheck="false" placeholder="Subject" data--100-bottom="transform:translate(0%,0px);" data-bottom-top="transform:translate(200%,0px);">
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<input type="submit" id="Button2" name="" value="SEND MESSAGE" style="display:block;width: 100%;;height:42px;z-index:19;" data--100-bottom="transform:translate(0%,0px);" data-bottom-top="transform:translate(400%,0px);">
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      <div id="Card1-card-item1">Kennel van de Malpieheide</div>
      <div id="Card1-card-item2">Fokker van Zwitserse Sennenhonden</div>
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<h3 id="Heading1">Ons laatste nieuws</h3>
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<p>Steeds vindbaar op facebook</p>
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<input type="text" id="Editbox1" style="display:block;width: 100%;height:34px;z-index:26;" name="email" value="" spellcheck="false" placeholder="Enter your email address">
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<div id="wb_Vakantie_boeken" style="position:absolute;left:103px;top:716px;width:747px;height:1406px;z-index:99;">
<form name="Vakantie_boeken" method="post" action="<?php echo basename(__FILE__); ?>" enctype="multipart/form-data" id="Vakantie_boeken">
<input type="hidden" name="formid" value="vakantie_boeken">
<div id="wb_Text4" style="position:absolute;left:24px;top:971px;width:697px;height:78px;text-align:center;z-index:30;">
<span style="color:#F5F5F5;font-family:Arial;font-size:17px;"><strong><em>Zonder geldige inentingen kan uw hond niet op vakantie komen.<br>Bewijs hiervan, bijvoorbeeld een dierenpaspoort of een entingsboekje moet u bij het brengen van uw hond meebrengen. <br>Dit blijft gedurende de vakantie bij ons i.v.m. eventuele controle door een overheidsinstantie. <br>Vereist voor de hond: cocktailenting, kennelhoest, hondenziekte en parvo.</em></strong></span></div>
<button id="Aankomst" type="button" style="position:absolute;left:25px;top:40px;width:97px;height:28px;z-index:31;" name="" value=""><p style="font-size:11px;line-height:12px;">Aankomst</p></button>
<input type="date" id="Aankomst1" style="position:absolute;left:136px;top:41px;width:184px;height:16px;z-index:32;" name="Aankomstdag" value="" spellcheck="false" title="Aankomstdag">
<label for="" id="Label15" style="position:absolute;left:353px;top:45px;width:69px;height:16px;line-height:16px;z-index:33;">'s morgens</label>
<div id="wb_RadioButton1" style="position:absolute;left:451px;top:47px;width:20px;height:20px;z-index:34;">
<input type="radio" id="RadioButton1" name="Aankomsttijd[1]" value="'s morgens" checked style="position:absolute;left:0;top:0;" title="Aankomsttijd[1]"><label for="RadioButton1"></label></div>
<label for="Text4" id="Label16" style="position:absolute;left:488px;top:47px;width:69px;height:16px;line-height:16px;z-index:35;">;s middags</label>
<div id="wb_RadioButton2" style="position:absolute;left:565px;top:47px;width:20px;height:20px;z-index:36;">
<input type="radio" id="RadioButton2" name="Aankomsttijd[1]" value="'s middags" style="position:absolute;left:0;top:0;" title="Aankomsttijd[1]"><label for="RadioButton2"></label></div>
<button id="Vertrek" type="button" style="position:absolute;left:25px;top:74px;width:95px;height:32px;z-index:37;" name="" value="" tabindex="2"><p style="font-size:11px;line-height:12px;">Vertrek</p></button>
<input type="date" id="Vertrek1" style="position:absolute;left:136px;top:77px;width:184px;height:16px;z-index:38;" name="Vertrekdag" value="" spellcheck="false" title="Vertrekdag">
<label for="" id="Label1" style="position:absolute;left:353px;top:74px;width:69px;height:16px;line-height:16px;z-index:39;">'s morgens</label>
<div id="wb_RadioButton3" style="position:absolute;left:451px;top:80px;width:20px;height:20px;z-index:40;">
<input type="radio" id="RadioButton3" name="Vertrektijd[1]" value="'s morgens" checked style="position:absolute;left:0;top:0;" title="Vertrektijd"><label for="RadioButton3"></label></div>
<label for="Text4" id="Label2" style="position:absolute;left:488px;top:74px;width:69px;height:16px;line-height:16px;z-index:41;">;s middags</label>
<div id="wb_RadioButton4" style="position:absolute;left:565px;top:80px;width:20px;height:20px;z-index:42;">
<input type="radio" id="RadioButton4" name="Vertrektijd[1]" value="'s middags" style="position:absolute;left:0;top:0;" title="Vertrektijd"><label for="RadioButton4"></label></div>
<div id="wb_Gegevens_van_de_eigenaar" style="position:absolute;left:24px;top:123px;width:340px;height:18px;z-index:43;">
<span style="color:#F5F5F5;font-family:Arial;font-size:20px;"><strong>Gegevens van de eigenaar:</strong></span></div>
<button id="AdvancedButton2" type="button" style="position:absolute;left:24px;top:153px;width:186px;height:43px;z-index:44;" name="" value="" tabindex="3"><p style="font-size:11px;line-height:12px;">Naam</p></button>
<input type="text" id="Naam_eigenaar" style="position:absolute;left:229px;top:154px;width:323px;height:30px;z-index:45;" name="Naam_eigenaar" value="" spellcheck="false" title="Naam eigenaar">
<button id="Mijn_adres" type="button" style="position:absolute;left:24px;top:210px;width:188px;height:43px;z-index:46;" name="Mijn adres" value="Adres" tabindex="4" title="Mijn adres"><p style="font-size:11px;line-height:12px;">Mijn adres</p></button>
<input type="text" id="Adres	" style="position:absolute;left:229px;top:210px;width:319px;height:33px;z-index:47;" name="Adres" value="" spellcheck="false" title="Adres	">
<button id="Postcode_woonplaats" type="button" style="position:absolute;left:25px;top:272px;width:187px;height:43px;z-index:48;" name="" value="" tabindex="5"><p style="font-size:11px;line-height:12px;">Postcode en Woonplaats</p></button>
<input type="text" id="Postcode" style="position:absolute;left:229px;top:272px;width:73px;height:33px;z-index:49;" name="Postcode" value="" spellcheck="false" title="Postcode">
<input type="text" id="Woonplaats" style="position:absolute;left:318px;top:272px;width:323px;height:33px;z-index:50;" name="Woonplaats" value="" spellcheck="false" title="Woonplaats">
<button id="Telefoonnummer" type="button" style="position:absolute;left:25px;top:336px;width:187px;height:43px;z-index:51;" name="" value="" tabindex="6"><p style="font-size:11px;line-height:12px;">Telefoonnummer</p></button>
<input type="text" id="Editbox2" style="position:absolute;left:232px;top:336px;width:323px;height:33px;z-index:52;" name="Telefoonnummer" value="" spellcheck="false" title="Telefoonnummer">
<button id="GSMnummer" type="button" style="position:absolute;left:24px;top:396px;width:186px;height:43px;z-index:53;" name="" value="" tabindex="7"><p style="font-size:11px;line-height:12px;">GSM nummer</p></button>
<input type="text" id="GSM_nummer	" style="position:absolute;left:232px;top:396px;width:323px;height:33px;z-index:54;" name="GSM_nummer	" value="" spellcheck="false" title="GSM_nummer	">
<button id="AdvancedButton1" type="button" style="position:absolute;left:24px;top:450px;width:188px;height:43px;z-index:55;" name="" value="" tabindex="8"><p style="font-size:11px;line-height:12px;">Email adres</p></button>
<input type="text" id="Email" style="position:absolute;left:232px;top:450px;width:323px;height:33px;z-index:56;" name="Email" value="" spellcheck="false" title="Email">
<div id="wb_Gegevens_van_de_hond" style="position:absolute;left:25px;top:528px;width:340px;height:18px;z-index:57;">
<span style="color:#F5F5F5;font-family:Arial;font-size:20px;"><strong>Gegevens van hond:</strong></span></div>
<button id="Naam_hond" type="button" style="position:absolute;left:24px;top:561px;width:188px;height:43px;z-index:58;" name="" value="" tabindex="9"><p style="font-size:11px;line-height:12px;">Naam hond</p></button>
<input type="text" id="Editbox3" style="position:absolute;left:232px;top:561px;width:323px;height:30px;z-index:59;" name="Naam_hond" value="" spellcheck="false" title="Naam_hond">
<button id="AdvancedButton5" type="button" style="position:absolute;left:24px;top:614px;width:187px;height:43px;z-index:60;" name="Ras" value="" tabindex="10" title="Ras"><p style="font-size:11px;line-height:12px;">Ras</p></button>
<input type="text" id="Ras" style="position:absolute;left:234px;top:614px;width:323px;height:30px;z-index:61;" name="Ras" value="" spellcheck="false" title="Ras">
<button id="Geboortedatum" type="button" style="position:absolute;left:25px;top:666px;width:187px;height:43px;z-index:62;" name="" value="" tabindex="11"><p style="font-size:11px;line-height:12px;">Geboortedatum</p></button>
<input type="date" id="Editbox6" style="position:absolute;left:232px;top:666px;width:323px;height:30px;z-index:63;" name="Geboortedatum" value="" spellcheck="false" title="Geboortedatum">
<button id="Chipnummer" type="button" style="position:absolute;left:25px;top:720px;width:187px;height:43px;z-index:64;" name="" value="" tabindex="10" title="Chipnummer"><p style="font-size:11px;line-height:12px;">Chipnummer</p></button>
<input type="text" id="Editbox4" style="position:absolute;left:234px;top:723px;width:323px;height:30px;z-index:65;" name="Chipnummer" value="" spellcheck="false" title="Chipnummer">
<button id="AdvancedButton4" type="button" style="position:absolute;left:25px;top:778px;width:185px;height:43px;z-index:66;" name="" value="" tabindex="12"><p style="font-size:11px;line-height:12px;">Geslacht</p></button>
<select name="Geslacht" size="1" id="Geslacht" style="position:absolute;left:226px;top:789px;width:127px;height:28px;z-index:67;" title="Geslacht">
<option value="Geslacht">Maak een keuze</option>
<option value="Geslacht">Reu</option>
<option value="Geslacht">Teef</option>
</select>
<select name="Geslacht_extra" size="1" id="Geslacht_extra" style="position:absolute;left:366px;top:788px;width:89px;height:28px;z-index:68;" title="Geslacht_extra">
<option value="Puur natuur">Puur natuur</option>
<option value="Gecastreerd">Gecastreerd</option>
<option value="Gesteriliseerd">Gesteriliseerd</option>
</select>
<button id="Loopsheid" type="button" style="position:absolute;left:371px;top:817px;width:100px;height:36px;z-index:69;" name="" value="" tabindex="13"><p style="font-size:11px;line-height:12px;">Laatste loopsheid</p></button>
<input type="text" id="Editbox5" style="position:absolute;left:481px;top:818px;width:147px;height:24px;z-index:70;" name="Loopsheid" value="" spellcheck="false" title="Loopsheid">
<button id="Sociaal" type="button" style="position:absolute;left:28px;top:844px;width:201px;height:43px;z-index:71;" name="" value="" tabindex="14"><p style="font-size:11px;line-height:12px;">Kan uw hond sociaal met ander spelen</p></button>
<select name="Sociale_hond" size="1" id="Sociale_hond	" style="position:absolute;left:246px;top:851px;width:86px;height:28px;z-index:72;" title="Sociale_hond	">
<option value="Ja">Ja</option>
<option value="Nee">Nee</option>
<option value="Weet ik niet">Weet ik niet</option>
</select>
<button id="AdvancedButton3" type="button" style="position:absolute;left:24px;top:902px;width:255px;height:43px;z-index:73;" name="" value="" tabindex="15"><p style="font-size:11px;line-height:12px;">Uw hond heeft alle geldige inentingen gehad</p></button>
<select name="Geldige_entingen" size="1" id="Geldige_entingen" style="position:absolute;left:294px;top:909px;width:86px;height:28px;z-index:74;" title="Geldige_entingen">
<option value="Geldige_entingen">Ja</option>
<option value="Geldige_entingen">Nee</option>
<option value="Geldige_entingen">Weet ik niet</option>
</select>
<div id="wb_Huisregels" style="position:absolute;left:42px;top:1310px;width:596px;height:54px;z-index:75;">
<p style="font-size:16px;line-height:18px;">Ik heb me op de hoogte gesteld van jullie huisregels en ik ga hiermee akkoord. </p></div>
<button id="Mededeling" type="button" style="position:absolute;left:42px;top:1198px;width:255px;height:43px;z-index:76;" name="" value="" tabindex="16"><p style="font-size:11px;line-height:12px;">Bijzonderheden  waar wij rekening mee moeten houden. Of een extra berichtje voor ons.</p></button>
<input type="text" id="Bericht" style="position:absolute;left:300px;top:1181px;width:411px;height:94px;z-index:77;" name="Bericht" value="" spellcheck="false" title="Bericht">
<select name="Huisregels" size="1" id="Combobox1" style="position:absolute;left:618px;top:1300px;width:86px;height:28px;z-index:78;" title="Huisregels	">
<option value="Ja">Ja</option>
<option value="Nee">Nee</option>
<option value="Weet ik niet">Weet ik niet</option>
</select>
<div id="wb_Captcha1" style="position:absolute;left:210px;top:1353px;width:202px;height:38px;z-index:79;">
<img src="captcha1.php" alt="Click for new image" title="Click for new image" style="cursor:pointer;float:left;width:100px;height:38px;" onclick="this.src='captcha1.php?'+Math.random()">
<span><input type="text" id="Captcha1" style="margin-top:12px;width:calc(100% - 10px);height:16px;" name="captcha" value="" spellcheck="false"></span></div>
<input type="submit" id="Verstuur" name="Verstuur" value="Versturen" style="position:absolute;left:434px;top:1353px;width:184px;height:49px;z-index:80;" title="Verstuur">
<div id="wb_Hond_vakantie" style="position:absolute;left:25px;top:5px;width:340px;height:14px;z-index:81;">
<span style="color:#F5F5F5;font-family:Arial;font-size:15px;"><strong>Mijn hond komt bij jullie op vakantie.</strong></span></div>
<div id="wb_Text6" style="position:absolute;left:36px;top:1100px;width:673px;height:143px;z-index:82;">
<p style="font-size:16px;line-height:18px;">Moet u hier nee of weet ik niet invullen dan moet u zo snel mogelijk naar uw dierenarts gaan. Let op: de entingen moeten minimaal 3 weken voor de vakantie zijn toegediend. </p>
<p style="font-size:16px;line-height:18px;">Anders kunnen wij uw hond helaas niet op vakantie laten komen.  </p></div>
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